Baby P case review: social workers urged to take victim into care if child abuse suspected

Suspected child abuse victims should sometimes be taken into care even if that assessment ultimately proves to be mistaken, a second review of the Baby P case recommended today.

After analysing the violent events that led to the death of the 17-month-old toddler, Graham Badman, chairman of Haringey's local safeguarding children board, urged social workers to adopt more of a precautionary principle of intervention.

"It is a big decision to remove a child from the care and ambience of their own family, especially when there is no decisive act which makes the decision for the professionals, and they will have to accept the full responsibilities themselves," the report said.

"There will be times when they have to grasp the nettle, using professional judgment, in the knowledge that they may be proved to be mistaken. Better that than the harm that the child will have to experience instead."

Yesterday's review of the case of Baby P, whose name was Peter, concluded that attempts to safeguard the vulnerable child lacked "urgency, thoroughness and were insufficiently challenging" to the mother. The agencies involved were not fully focused on the boy's welfare and "adopted a threshold of concern for taking children into care that was too high".

The second review was commissioned after the Ofsted inspectorate evaluated the first serious case review as "inadequate". The 27-page executive summary of Badman's reportfound that "Baby Peter's death could and should have been prevented".

It acknowledged that the boy "deserved better from the services that were there to protect him".

Badman's suggestion that it is better to err on the side of caution in care proceedings does not feature in the final list of detailed recommendations in his report. But at a press conference he said he hoped the result of his review would be that agencies were more willing to "pick up the phone" to raise concerns.

His account highlighted legal opinion provided in December 2006 following an early child protection case conference for Peter in Haringey. The advice was that "the threshold for care proceedings had been met", but, the report noted, "this did not prompt the Children and Young People's Service to initiate care proceedings in respect of Peter".

Even after Peter was put under a child protection plan, the report found, his case was regarded as routine "with injuries expected as a matter of course".

Agencies "did not exercise a strong enough sense of challenge" when dealing with Peter's mother and their outlook was "completely inadequate".

Badman's inquiry criticised those involved for adopting the view that "nothing less than injuries that were non-accidental beyond all reasonable doubt would have caused him to be moved to a place of safety". The review added: "When such injuries did come, they were catastrophic, and he died of them."

Badman, a former adviser to parliamentary select committees and visiting professor at the University of London, accepted that the professionals involved were neither under-trained or fundamentally incompetent. All were "appropriately qualified, well-motivated and wanted to do their best to safeguard him". But, he cautioned, "they did not apply the competence that was expected." The most important lesson, Badman said, was "that professionals charged with ensuring child safety must be deeply sceptical of any explanations, justifications or excuses they may hear in connection with the apparent maltreatment of children.

"If they have any doubt about the cause of physical injuries or what appears to be maltreatment, they should act swiftly and decisively. If doctors, lawyers, police officers and social workers had adopted a more urgent, thorough and challenging approach, the case would have been stopped in its tracks at the first serious incident."

The care workers were too preoccupied with keeping Peter in the family rather than ensuring his ultimate safety, the report said. Not enough was done to establish the role and identity of the mother's boyfriend. Social workers at the council maintained that they did not suspect the mother was harbouring a violent boyfriend in the house but they should have been alert to his presence.

The serious case review found: "At no point did it occur to anyone that the injuries to the children were caused by someone else apart from their mother. On the basis of her observed interactions with her children it seemed to be incongruous and unlikely to be her. There should have been a greater pursuit of this man and his likely role. Much more attention should have been paid to the role of this man entering this vulnerable family."

Care proceedings should be initiated when it is believed parents are not being frank or co-operating with the authorities, Badman said. The manipulative and deceptive behaviour of the mother, Badman warned, was "no mitigation" for social workers and agencies.